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Neurofeedback with Anxiety and Affective Disorders
Journal of Child & Adolescent Psychiatry Clinics of North
America, Jan. ‘05
(This article has been lightly edited by David Dubin, MD to make it more accessible to a
general public.)
D. Corydon Hammond, PhD, ABEN/ECNS
Physical Medicine and Rehabilitation, University of Utah School of Medicine,
Compelling evidence exists for a neurophysiologic basis for obsessive-
compulsive disorder (OCD). There is also strong research evidence also
indicates that there are functional brain abnormalities associated with anxiety and
panic disorder [28–30] and post- traumatic stress disorder (PTSD) [31].
There is a strong reliance in psychiatry on the use of medication for the treatment
of depression and anxiety, although some evidence currently suggests that
medication may not be as effective in treating these conditions as has often been
believed [44–48].
Similarly, Greist [49] estimated the degree of symptomatic improvement in OCD
from treatment with serotonin drugs to only be 30%. Goodman et al [44] similarly
found that symptom amelioration in OCD treatment with serotonin uptake
inhibitors is approximately 35% on average and that only 50% of patients
experience this partial improvement.
In light of this brief review and the fact that an increasing number of patients and
parents seem interested in non- medication treatment alternatives that still
address the underlying biologic factors associated with depression, anxiety, and
obsessive compulsive disorder (OCD), it would be desirable to find a treatment
that also would help address the biologic aspects of mental health disorders.
Neurofeedback holds promise for offering such an alternative.
What is neurofeedback?
Neurofeedback is EEG biofeedback or brain wave training. Nothing intrusive is
introduced into the brain. The sensors simply measure the ongoing brain wave
activity.
Ordinarily we are unable to reliably influence our brain wave activity because we
lack awareness of it. When we are able to see representations of our brain wave
activity on a computer screen a few thousandths of a second after it occurs,
however, it allows us to modify our brain wave patterns through operant
2
conditioning.
The patient is placed in front of a computer screen. The computer display may
be as complex as a computer/video game type of display. It also may be as
simple as two bar graphs, one representing slow and inefficient brain wave
activity and the other representing efficient, beta brain wave activity. The patient
concentrates on the screen. When the inappropriate activity decreases slightly
and the appropriate activity increases slightly, a pleasant tone might be heard.
At first, changes in brain wave activity are transient. As sessions are repeated,
enduring changes are gradually seen.
EEG biofeedback (neurofeedback) has been found to be effective in modifying
brain function and producing significant improvements in clinical symptoms in
children, adolescents, and adults who have several different biologic brain
disorders.
These conditions include epilepsy, attention deficit disorder and attention deficit
hyperactivity disorder (ADHD), and learning disabilities and have included up to
10-year follow-ups of patients [57].
Neurofeedback for anxiety
A review of the literature on the neurofeedback treatment of anxiety disorders by
Moore [58] identify eight studies of generalized anxiety disorder.
The best studies of neurofeedback with anxiety were three outcome studies [59]
with phobic (test) anxiety. In each study, the group that received alpha EEG
enhancement training demonstrated significant reductions in test anxiety. In
comparison, the untreated control group and the relaxation training group
experienced no significant reduction.
In another study, with alpha training the anxiety scores dropped significantly
compared with a non-treatment group. Moore [58] concluded in his review that a
placebo effect was present in these neurofeedback studies but that alpha and
theta enhancement training provided additional effects beyond placebo and are
effective treatments for anxiety disorders.
Passini et al [70] used 10 hours of alpha neurofeedback training, comparing 25
anxious patients (23 of whom were alcoholics) with a control group of 25 anxious
patients (22 of whom were also alcoholics), most of whom were seeking
treatment at a Veterans Administration hospital brief treatment unit. The alpha
neurofeedback training produced significant changes in state and trait anxiety
compared with controls.
An 18-month follow-up of those patients was published, with virtually identical
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results of lower anxiety still found, which validated that the anxiety changes from
alpha neurofeedback were enduring [71].
Two neurofeedback outcome studies have focused on chronic PTSD. In a
randomized, controlled group study [73], 30 30-minute sessions of alpha-theta
EEG biofeedback training were added to the traditional Veterans Administration
hospital treatment that was provided to a group of 15 Vietnam combat veterans
with PTSD. The study compared them after treatment and at follow-up with a
contrast group of 14 veterans who only received traditional treatment.
In addition to the posttreatment testing, on a monthly basis, patients and
informers were contacted for a full 30-month follow-up period to determine if
there had been PTSD symptoms (eg, flashbacks, nightmares, anxiety attacks,
depression).
At follow-up, all 14 traditional treatment patients had experienced relapse,
whereas only 3 of 15 neurofeedback training patients had experienced relapse.
All 14 patients who were treated with neurofeedback had decreased their
medication requirements at follow-up, whereas in contrast, only 1 traditional
treatment patient had decreased medication needs, 2 reported no change, and
10 required more medications.
Neurofeedback training patients improved significantly on all ten MMPI clinical
scales—in many in- stances dramatically—but there were no significant
improvements on any scales in the traditional treatment group.
In another Veterans Administration hospital uncontrolled study [74], 20 Vietnam
veterans with chronic PTSD, all with alcohol abuse, were randomly selected. All
patients showed frequent (eg, two to three times per week) episodes of PTSD
and had been hospitalized for PTSD an average of five times.
They were treated with 30 30-minute sessions of alpha- theta neurofeedback
training. Follow-up interviews occurred with the patients and their wives or family
members on a monthly basis for 26 months. In that time, only 4 of the 20 patients
reported a few (one to three) instances of recurrence of nightmares or
flashbacks, and the other 16 patients had no recurrence of PTSD symptoms.
Neurofeedback for depression
Although reports to date on the application of neurofeedback to depression
only represent uncontrolled case reports, they provide encouragement that
neurofeedback may hold potential for treating mildly to severely depressed
patients and that unlike medication, it may enduringly modify the functional brain
abnormality associated with biologic predisposition to depression.
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Clinical experience and further case examples
Based on clinical experience with more than 25 patients with dysthymia, in
which most of them have been followed for between 6 and 24 months,
neurofeedback has seemed to be successful in producing significant and
enduring change in approximately 80% of the patients. There have been no
published research or clinical reports on the use of neurofeedback in a pediatric
depression sample. Because the biologic marker of a frontal alpha asymmetry
has been found in multiple studies with children and infants [38–41] of depressed
mothers, and because there is abundant evidence that children respond to
neurofeedback training for other conditions, it is reasonable to expect that this
approach would be beneficial with depressed children.
There are widespread clinical reports of improvements in mood among children
treated with neurofeedback for ADHD, which further supports the expectation
that neurofeedback may be effective with childhood depression. There also are
reports of improvements in bipolar disorder.
Neurofeedback seems to involve minimal risk of side effects or adverse reactions
[84], and it is less invasive than antidepressant medication or transcranial
magnetic stimulation.
Anxiety and insomnia
In most cases, anxiety and insomnia are readily treated with neurofeedback
[58,59,85–88]. One of the first improvements that parents often notice is that the
child falls asleep more easily and remains asleep. With anxiety patients,
neurofeedback training often is done eyes closed while listening to auditory
feedback, and in a sense it resembles high-technologic meditation training.
As a case example, a patient was referred by a physician who was a headache
specialist, indicating that everything that could be done with medication seemed
to have been done. The patient had a lengthy history of several migraines
weekly, which had progressed to daily migraines. She had been given a self-
hypnosis tape to use for anxiety management, but she complained that her mind
was so busy that she was unable to obtain much relaxation from the tape. After
20 30-minute sessions of inhibiting fast beta and reinforcing alpha activity in the
parietal area, she was off all her prescription medications. She sensed a
migraine trying to begin approximately twice weekly but would take over-the-
counter medication and could use the self-hypnosis tape successfully to abort the
headache. She felt more relaxed in general and reported no longer feeling
compelled to do two things at once.
5
Summary
As reviewed in other articles, the neuroscience technology known as EEG
biofeedback (or neurofeedback) has considerable research support in areas such
as uncontrolled epilepsy and attention deficit disorder and ADHD. In evaluating
the studies in the overall broad area of the neurofeedback treatment of anxiety
disorders, EEG biofeedback qualifies for the evidence-based designation of
being an efficacious treatment [62]. When separate anxiety disorders are
individually evaluated, the areas of phobic anxiety, generalized anxiety, and
PTSD each qualify for designation as being a probably efficacious treatment.
Currently there are only reports of cases and series of cases on the treatment of
depression and OCD and no published reports thus far on treatment of bipolar
disorder. Despite the lengthy follow-ups and use of objective measures,
neurofeedback treatment for depression and OCD is not yet empirically
supported. EEG biofeedback is an exciting, cutting-edge technology that offers
an additional treatment alternative for modifying dysfunctional, biologic brain
patterns that are associated with various psychiatric conditions.
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